Approach to Geriatric pt Flashcards
Five domains of geriatric assessment
Medical, Mental, Physical, Environmental, Care preferences
Medical assessment includes…(6)
Present and past illnesses Meds Nutrition Hearing and Vision Pain Urinary incontinence
Mental assessment includes…(3)
Cognitive status
Emotional status
Spiritual status
During a mental assessment, what aspect is often overlooked?
Spiritual status
Physical assessment includes…(3)
Functional status
Balance and gait
Falls
Environmental assessment includes… (3)
social history (occupation, education, etc)
Financial status
Environmental hazards
Care preferences refers to…(3)
Goals of care
POLST/Advanced Directive
Power of Attorney.
What does POLST stand for?
Physician’s Orders for Life Saving Treatment
Can you bill for time spent advising a patient on end of life decisions?
yes
Dealing DIRECTLY with a patient enhances these 3 things
preserve personal dignity
promote connection and trust
instill meaning in your encounter
Should you call your patient by his or her first name?
No, use their surname
When a patient is speaking slowly, should you complete their sentences for them to move things along?
no
what can family members help with for history?
Fill in gaps and corroborate details if needed
Why do patients under-report pain?
Think it’s normal
Fear of illness or disability
Lack of concern d/t depression
What is the most accurate way to get an idea of what medications the patient is taking?
Have them bring them in.
Things included in social history?
Sex, drugs, alcohol Hobbies, social life Employment history Economic status Relationships with family/friends Living arrangements
GI ROS questions (4)
chewing difficulties, dysphagia, constipation, bowel incontinence
GU ROS questions (3)
difficulty urinating, urinary incontinence, sexual dysfunction
MSK ROS questions (1)
diffuse or focal pain
Nuro ROS questions (4)
sensory changes, gait instability, recent falls, focal or diffuse weakness
ROS special addition
Pain
Psych ROS questions
Depression, anxiety or agitation, forgetfulness or confusion
What are ADLs?
Activities of daily living: toileting, feeding, dressing, grooming, ambulation, bathing
What are IADL’s?
Instrumental Activities of Daily Living: use the phone, shopping, food prep, housekeeping, laundry, transportation, medication management, finance handling
Can you get a full, holistic assessment done in one visit?
No, must take place over multiple visits and follow-up is essential
Can you provide full, holistic care by yourself?
no, it’s a team effort
Who is involved in complete care of geriatric patient? (12)
Medical provider PT/OT Speech Therapist Social Workers Pharm Dentist Audiologist Specialist providers Nurses Nutritionist Clergy if appropriate Family members
What can an audiologist provide?
Hearing evaluation, hear aid fitting
What can a dentist provide?
oral care. denture fitting. referral to specialists
What can a pharmacist help with?
ID meds with possible adverse reactions.
Recommend safe alternatives.
Prevent polypharmacy
What can a PT help with?
balance and gait, fall risk
provide therapy and modifications for treatment
What can an OT help with?
screening for ADL and IADLs. Home evaluation for safety. Provide modifications
What can Speech Therapist (ST) help with?
eval and treat swallowing difficulties
provide speech therapy
Can ST help people with neuro or cognitive deficits communicate better?
yes
What will a social worker help with?
assess risk for abuse
investigate suspected abuse
help find community/home services
What will a nutritionist/dietician help with?
food
What is the goal BP for elderly?
SBP
What is goal BP for someone with DM or CKD?
SBP
What kind of BP should you check?
orthostatic
What if you find an irregular pulse?
Remember that it’s not uncommon. If it’s new, get an EKG
2 things to add to differential if there is a weight gain
Heart Failure
Ascites
How much weight loss for it to be worrisome?
more than 5% over 1 year
What could alert you to poor ADL fxn or abuse/neglect?
poor grooming
If new onset of slowed speech, 2 things to think about
cognitive decline, parkinsons
What does turgor indicate?
dehydration
Big thing in skin exam to look for…
pressure ulcers. think reduced immobility or neglect
If they can hear normal convo, what should you do?
whisper test
If reduced vision, what is part of your plan?
refer to opthalmologist
If stroke suspected, what vision should you test?
confrontation
What common thing might you find in someone’s mouth?
thruth
If you hear bibasilar crackles, what should you think?
pulmonary disease, or, if no other symptoms…
atelectasis
What might make posterior lung exam hard?
kyphosis
If you see an abdominal pulsation, what gets added to differential?
AAA. get ultrasound
If the patient is thin and constipated, what might you palpate?
their stools
What might you see on testicular exam?
atrophy
What might you see on vaginal exam?
atrophy and dryness. very common
Common occurrence with bladder or bowel?
prolapse
What is periarticular swelling?
joint swelling
Common labs that are affected by age…(8)
sed rate glucose creatinine albumin alkaline phosphotase Iron, TIBC, ferritin PSA UA
common abnormal for Sed rate (up or down)?
mild elevation
common abnormal for glucose?
tolerance decreases. elevated during acute illness
Creatinine age changes
lean body mass decreases. higher end of normal or small elevation can mean SUBSTANTIAL decrease in renal function
Albumin age changes
low levels usually indicate POOR NUTRITION in absence of liver disease, proteinuria, or absorption issues.
Alkaline phosphatase age changes
mild asymptomatic elevations are common
Iron, TIBV, Ferritin age changes
decreased values mean poor nutrition or GI blood loss
PSA age changes
may be elevated with BPH. trending up or acute rise need further evaluation for prostate CA.
What lab changes might indicate poor nutrition?
low iron, TIBC, ferritin.
low albumin/prealbumin
UA age changes
asymptomatic UTI common.
Should you treat an asymptomatic UTI?
no
What 3 levels of measurement when evaluating ADL and IADL?
- ability to perform task independently
- ability to perform task with some assistance
- inability to perform task, even with assistance.
Ways to measure/track cognitive capacity
Mini-cog
Mini Mental Status Eam
MOCA, SLUMS
Most common test used for cog assessment
Mini Mental Status Exam
Depression screening tools (2)
Quick: PHQ-2
Most common: PHQ-2
What are the 2 main questions on the PHQ screens?
Little interest/pleasure in doing things
Feeling down/depressed/hopless
These are the 2 on PHQ-2. also on PHQ-9
Ways to eval gait and balance (4)
Get Up and Go Test
POMA (performance oriented mobility assessment)
Stance: semi-tandem, full tandem (heal to toe)
Functional Reach Test
What can a comprehensive geriatric assessment look at?
Everything pretty much, but also help determine is patient has capacity to make own decisions.
When do you need a comprehensive geriatric assessment?
perceived need to transition to a higher level of care
Are geriatricians easy to find?
nope
What can a geriatrician help with?
Comp ger. assessement
Help with specific problems (cog changes, recurrent falls, incontinence)
Pre-op eval of high-risk pts
Remember this about treatments for geriatric patients…
therapy (physical or pharm) can help one thing and make something else worse.
Balance every options pro and con!
What is most important to geriatric patients?
You need to ask him or her.
living as long as possible
being pain free
maintaining function
depends on what the person wants
2 spots to find evidence based practice advice
American Geriatric Society position papers
Choosing wisely
What to take into account when discussing the plan
Cost
Risk and side effects
Clear descriptions of expected outcomes
Always include this in decision making process
Prognosis
Why prioritize decisions based on life expectancy?
to minimize tx unlike to provide benefit
limit harms without benefit
what are the 4 principles of medical ethics?
autonomy
beneficence (well-being)
non-maleficence
justice
How do you know what a person’s prognosis is?
use the tools available
Clinical feasibility and individual preferences have what effect on the assessment and plan?
They SHOULD inform treatment choices
